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Growing up too fast

Appeared in DIVER June 2001

A big push is underway in international diving, to encourage children to go diving and get hooked before other pursuits take their fancy. But accidents have already occurred - are we on a slippery nursery slope Steve Warren investigates

Appeared in DIVER June 2001

Growing up too fast

A big push is underway in international diving, to encourage children to go diving and get hooked before other pursuits take their fancy. But accidents have already occurred - are we on a slippery nursery slope Steve Warren investigates

SEARCH TEAMS TOOK TWO HOURS TO RECOVER THE BODY OF JEREMIAH DOUGLASS. He died alongside his father after a dive to free a fouled anchor at 40m went badly wrong. He was just 14. Two years later, in 1997, three more children lost their lives diving. An untrained 12-year-old embolised after ascending while breathing from his dads set. A 14-year-old apparently ran out of air while ascending from a spear-fishing dive to 30m with his father. And a boy of 15 died from an embolism following free-ascent training during the first dive of a scuba class. These four deaths occurred in North America. Two of the USAs most successful training agencies, PADI and SSI, have since lowered the age for scuba certification from 12 to 10. Should we expect more casualties And should parents think twice before enrolling their children on scuba courses PADI International expresses confidence in its decision, though with certain caveats. PADI thinks its appropriate to teach 10-year-olds to dive, whether in British, Swedish, Canadian, South African or any other waters, with the same proviso that applies to any age group, that the student is physically and mentally mature enough to cope with the requirements of the course, says Eric Albinsson, Training, Quality Management and Memberships Manager. Another factor to consider is whether or not appropriate and properly fitting equipment can be found for the diver. If the instructor and/or parents do not feel the student is mature enough for the course or suitable equipment cannot be found, then we would not expect our instructors to teach the diver at that time. So considerable judgment is required on the part of adults involved in training a child. Small wonder the decision to pursue the child market has divided the industry. The in-fighting encompasses a raft of issues ranging from the moral to the medical, equipment to supervision and whether any risk to children can ever be acceptable in pursuit of profit. Until the mid-80s, most US-based agencies placed the onus on the instructor to decide when a child was old enough to dive. Following a drawn-out legal action after a 10-year-old boy died under tuition, the agencies drew up new guidelines and agreed a formal minimum age limit for scuba training of 12. By setting an industry standard, competing training agencies would be able to present a united front in the event of lawsuits and restrictive legislation. Insiders admit privately that the scuba-diving industry is in trouble. Diving nowadays has to compete with cheaper, easier, more accessible and more attractive activities for peoples time and money. And in future there will be fewer people to whom the industry can appeal, as the baby-boomers fail to regenerate as enthusiastically as their parents. Progressive agencies such as PADI have worked hard to attract more people into the sport. They have reinvented diving. It is no longer the preserve of the male lifestyle diver indulging his passion locally during every free moment, but another pastime for Everyman to enjoy on occasional overseas holidays. In growing the market, PADI made a macho sport a lazy recreation and went for an Access All Areas policy. It has pursued the older market, the disabled and, in a recent about-face, is even promoting technical diving. Now it wants the youth. Both PADI and SSI are now taking the battle for converts to the young front line because, by capturing children early, they hope to engage their interest and profit later from hanging on to them. If they dont, they argue, they will lose them to other pursuits, probably for good. Traditionally, British diving organisations have not encouraged young divers. This has had as much to do with the adult club culture of not wanting children around as with safety arguments. The Scottish Sub-Aqua Club, the oldest agency in the UK, maintains 15 as the lower age limit for scuba training. For the Sub-Aqua Association, it is 12. The British Sub-Aqua Club finds itself in a dilemma. Unlike the strictly amateur SSAC and SAA, it chose to compete with the big American agencies through a professional schools wing. While BSAC Schools offer certification courses to 12-year-olds, the non-profit branches have so far rejected proposals from the clubs leadership to reduce the age limit for diving with them from 14. This has already led to complaints and embarrassment for the club. But might this refusal to cave in and lower age limits have helped prevent tragedies similar to those that have happened in the USA And why are some of divings most respected individuals from the fields of education, safety and medicine opposed to making scuba training available to youngsters

Children, risk and panicA traditional argument against allowing children to dive is that they are not emotionally mature enough either to foresee or handle emergencies. This is an opinion shared by some of the industrys hardest-hitters. Karl Huggins is a respected decompression researcher and co-inventor of the EDGE dive computer. He is now Program Director at the chamber on Catalina Island off California to which Jeremiah Douglass was brought. Emphasising that he was giving me his personal views, Huggins explained: While I do think there are some young people who can understand the concepts, sometimes better than adults, and adapt easily to be very comfortable in the water with scuba, what they do lack is a sense of mortality and the understanding that a mistake may kill them or leave them paralysed for the rest of their life. William Morgan of the University of Wisconsin has studied panic in adult divers. In a condemnation of the recreational diving industry, Morgan wrote in a paper, Anxiety and Panic in Recreational Divers: There is evidence that the role of panic in diving accidents and diving fatalities has not received adequate attention from diving professionals. At least one researcher has suggested that the inherent risks of scuba-diving have been downplayed by commercial interests and that figures supporting the view that diving is a very safe sport are being fudged. Morgan quotes figures indicating that more than half of experienced divers have encountered panic situations. This suggests that in the normal course of events many children will have a frightening dive. How they will react to that is anyones guess.

Early appliance of scienceRisk and panic apart, not everyone is convinced that 10-year-olds can get a handle on the theory involved in diving safely. Andrew Pugsley is 19 and started diving at 12. Now a BSAC Assistant Club Instructor, he holds a swathe of BSAC, PADI, NAUI and IANTD qualifications. I have been actively involved in training youngsters aged 14 to 17 since the age of 15, says Andrew. My feeling is that children as young as 10 are capable of learning the concepts of physics to a level required for scuba training, though they may require more coaching. This is very subjective - some kids will be better than others. But he goes on: I see the main problem as being whether they want to learn it. They lack the sense of danger, or healthy respect, for the underwater environment, and they dont appreciate that they are being taught physics for a reason - that it is relevant to their safety. An experienced full-time British PADI instructor told me: I would not be confident in a childs ability to assimilate the necessary safety information needed to learn to dive, and I would not be happy with a parents perception that their child was able to dive unless they themselves were divers. Fears that parents might encourage children to dive before they are ready are nothing new. Butch Hendricks, one of the worlds leading diving safety experts, adds to the debate on parental pressure: I am concerned about 10-year-olds who barely get by in school, with parents who have barely a basic knowledge of diving, basic lung expansion injuries, and possible bone density problems. I am concerned about the parents who think they have a child who can do more in the water than the average child and therefore should be allowed to push the envelope. Children are children, and testing limits is the nature of childhood. Fred Colburn, a diving instructor at a centre used by the father of Jeremiah Douglass, said of the boy: He was as experienced as you could get for a 14-year-old.

Bones, bubbles and eardrumsConcerns that diving might affect bone growth have been mooted. US training agency NAUIs website carries an article first published in 1991 by Dr R Kelly Hill. He writes: Juveniles have a unique tissue group risk for decompression sickness. Though all of a juveniles tissues are in transition, one tissue type in particular is at potential risk of DCS: bone. As the skeleton grows, it does so by lengthening bones at their ends, through the growth plates. The growth plates have their own set of on- and off-gassing parameters, and they are the ones not necessarily included in the testing of decompression schedules. If a growth plate dies, the bone is permanently distorted. The risk is real and the incidence unknown. Diving is a wonderful experience, but there are lots of wonderful experiences open to kids, like growing up with two legs of equal length. There have been suggestions that other time bombs might lie in wait for the child diver, including bone necrosis, normally associated with commercial divers who routinely make decompression dives. Necrosis is caused by bubbles blocking gas exchange to the bones and causing them eventually to collapse. However, Alfred Bove, one of the most respected specialists in dive medicine, cautions about jumping to any conclusions about bone damage. There is no evidence that any problems will occur from early diving. Most people with bone necrosis of the tibial tubercle have not been diving, and to blame diving on the known aseptic bone problems in childhood and adolescence is not correct. As our knowledge of decompression theory inches ahead, we have changed the way we dive - slow ascents and safety stops are comparatively recent innovations. Even today, the proliferation of dive tables and computers underlines a lack of consensus about what constitutes a safe dive schedule. In years to come, will we look back on how we dive now and regret the profiles we put our children through Maximum depth limits of 12m have been set for 10- to 12-year-olds and only no-stop dives may be made. It is hoped that these limits will prevent youngsters being hurt. However, a recompression chamber in Belize has reported treating an 11-year-old boy for arterial gas embolism (AGE) after he made two dives to 9m for 40 minutes during training. It is commonly accepted that decompression hits can occur well within the no-stop limits. A chief suspect is the Patent Foramen Ovale or PFO, a flap in the heart that separates arterial and venous blood. Before birth, babies dont breathe through their lungs and this opening allows blood to flow freely through the heart. After birth the baby uses its lungs, and the hole should seal. Almost any dive creates a certain amount of bubbling. Usually the bubbles are small and ride in the venous blood to the lungs, which filter and eliminate them harmlessly. Estimates vary widely, but it is suspected that in 10-30 per cent of the population the hole in the heart fails to seal completely. For divers of any age, this has serious implications. A PFO can allow bubbles in the venous blood to pass through and into the arterial blood supply. From here, they will be delivered to the tissues and can result in decompression injury. Detecting a PFO requires invasive procedures involving injecting bubbles into the bloodstream. It is unpleasant and expensive and screening is not normally included even in commercial diving medicals. PADI and SSI dont require students to undergo a medical before diving, unless a child or its parent answers yes on a standard dive industry medical form. PFO tests are most commonly ordered after a diver gets bent. PFOs are also linked by some medical professionals to lesions found in the brains of some divers. Its early days, and different studies are turning up conflicting results. According to Bove: The data on brain lesions is poorly controlled, and is not currently accepted as fact in the medical community. This can only be determined by a prospective study, which has not currently been done. In a statistical evaluation of decompression sickness risk with PFO, Bove found a slight increase but not enough to influence any medical opinion about diving with a PFO. As always, the number of subjects used in the studies is statistically small. For parents thinking of letting children dive, the uncertainty surrounding possible long-term brain injury must factor in. When it comes to physical ability, ear problems present another area of concern. Dave Hack, Managing Director of Capernwray Diving Centre in Lancashire, says: We had a child in our shop crying with agony with blood running from his ears because he had dived with grommets in place which had become forcibly dislodged during the dive. Nobody had told the instructor, though he had a signed medical self-certification form! Young children have smaller Eustachian tubes and most have great difficulty in clearing their ears - its hard enough for most adults.

Thinking the unthinkableNo one knows how many divers there are, how often they dive or how they dive, so most statistics concerning recreational diving safety are extremely suspect. Few studies have been conducted, and those that exist have been modest in scope. The subject receives little funding, and time and again guesswork is passed off as fact. Although the industry points out that children can be killed or injured doing almost any activity, scuba-diving often causes injuries which require unique treatments and facilities. A child who falls off his bike or is run over in a major European city stands a reasonable chance of being evacuated quickly by ambulance or helicopter to a hospital with the proper trauma facilities, often within the so-called golden hour. A child with DCS, AGE or a lung expansion injury might be less lucky. That many diving locations are situated far from major population centres is often the attraction. But it is dangerous to assume that a flashy resort with a swimming pool, wet bar and luxury dive boat also has a recompression chamber. Few dive centres operate their own chambers. They rely on the goodwill of military and commercial bodies to loan their equipment and expertise in the event of an accident. Even if a chamber exists, it might not be manned, in service, or equipped with advanced life-support equipment needed to treat a serious diving accident. Divers sometimes dont realise that pain relief might have to be withheld to some extent to help assess treatment - a sobering thought for any parent. The reality is that many popular diving destinations lack the infrastructure necessary to evacuate or treat an injured child diver.

Getting gear to fitChild divers dont simply need smaller equipment. Their different body shapes require gear designed specifically for them. Supervisors also need to understand that children lack the strength of a similar-sized adult. It is harder for them to dress in and out of equipment, propel themselves through the water and operate stiff power inflators or releases, for example. They also chill more quickly. Adding a thicker dive suit adds to the weight they need to carry to offset the extra buoyancy, while making it harder to swim against the restriction of the neoprene. In the incident that led to US training agencies setting a formal age limit of 12 to become a certified diver, ill-fitting equipment was thought to have played a role. BCs in particular have to be properly sized. A jacket that is too big will either let the child fall out or allow it to float at near mouth-level when inflated at the surface. Too small and it might have inadequate lift, or restrict a childs breathing when inflated. Wrongly sized jackets will also prove unstable. Badly positioned cummerbunds and waist straps might interfere with the emergency jettisoning of weightbelts. Martin Parker of Buddy BC maker AP Valves describes children diving as one of the most exciting developments in the sport over the last years. Their enthusiasm during pool sessions is infectious and the enthusiasm of the supporting parents is something to behold. Diving is safe, diving is fun - its the right message to be sending out. However, he adds a note of caution on equipment. Im not sure all the instructors understand the problems they could face should this party turn sour. Look at what some children are doing: diving with an air cylinder with very limited capacity attached to a jacket that is most likely to push the sprogs head under water. Just as bad, if a large jacket is used it might float just nicely, with poor Freddie hanging in it trying desperately to hold his head above water! These little guys are going in the water with full trust in their instructor and equipment. The parents are thinking: Its only shallow, hell be able to stand up should anything go wrong, and after all, the instructor knows what hes doing. The last thing they expect is that the equipment choice could actually cause a drowning. Getting the correct fit is essential and instructors should be wary of parents buying a big-size jacket for their child, thinking hell grow into it. According to Margaret Baldwin of the Stoney Cove inland site, where children under 12 are not allowed to dive: Young people are frequently given ill-fitting equipment and suits to use. Were aware that vigilance by our staff has prevented the use of ill-fitting equipment leading to a serious problem. Very few dive shops and clubs stock semi-dry suits, let alone drysuits, in child sizes, says Dave Hack of Capernwray, which also excludes divers under 12. Weve had children brought into the shop who were medically hypothermic because the suit they were given was two sizes too big, or the neck seal on a drysuit was about three inches too big and someone had tried unsuccessfully to seal it with a knife strap. Eric Albinsson of PADI says the decision of centres to exclude under-12s is one they are free to make. Our understanding is that their decisions may have been based on a consideration to allow a period of review, to see, for example, how equipment manufacturers responded to the need for smaller-sized BCs and suits if indeed such a need arose. Scuba tanks are long-lasting - 20 years is not uncommon. Many aged tanks are therefore still in service at resorts. However, older tanks, like the ubiquitous American aluminium 80s often found in rental, are long, similar in size and weight to a UK-spec steel 12 litre, and even smaller adult divers often find these uncomfortable. Tank positioning plays a major part in trim control. Placing the tank high brings the diver into a more streamlined and efficient horizontal attitude. For a childs short torso, a longer cylinder can be problematic. Place it low and the child cant easily sit down. Under water, he will be dragged into a head-up, feet-down position. Place it high and the child will crack his head every time he looks up. Any part of the tank that is clear of the water will tend to push the diver down. Even proper weighting can be an issue. Some dive centres supply only block weights of 2kg or more. This does not allow enough discretion for fine-tuning of buoyancy and, with a small-lift BC, erodes safety margins. Diving equipment often features in incidents - sometimes its the wrong gear for the job, sometimes its simply badly maintained, and sometimes its misused. It is also costly. Parents might be unwilling to outfit their children properly if they think equipment will see only a seasons use before it is outgrown. It remains to be seen whether all dive centres offering diving to children will invest in the proper equipment for this special-needs market.

Buddies at riskOne obstacle to training youngsters has been the fear that in an emergency they would not be able to save an adult partner. Declining to be named, a source from the medical community stated: After reviewing some double-fatality statistics, I found both father/son and father/daughter tragedies. Could a child save an adult, or even another child, if there was a potentially life-threatening emergency under water Physically, a child is not capable of rescuing an adult in the water, and when diving both buddies need a competent and able-bodied buddy. Its a valid point. Although first-aid training is available to youngsters through PADIs Medic first-aid course, neither Rescue nor O2 Administration is. It is unlikely that a young child could rescue either another child or an adult. The risk assessments have parallels with normal divers who might also lack these skills, buddy teams where there are significant differences in size, or disabled divers who might not be able to make a rescue. In all these cases, risks have to be identified, and the divers concerned may choose to accept them, find solutions or cancel the dive. Butch Hendricks company Lifeguard Systems trains both public safety and recreational divers to make rescues. The standards require that the parent or adult guardian dive with the child after the childs certification, he says. What are we doing to train parents to make informed decisions and be responsible, capable dive supervisors A parent diving with a child is in effect solo-diving. What have we done to train these parents to dive alone James Stewart is another US diving icon. Ex-Underwater Demolition Team, he went on to become Diving Officer of Scripps Institution of Oceanography, designing the safety standards that are the bible for scientific diving teams. He has made - and trained others to make - extraordinary dives in the name of science. A diving veteran of some 60 years, few can claim a greater grasp of safety issues. Stewart told me: Ive long believed that young children should not dive. After investigating fatalities for LA County, Ive seen a number of accidents where the adult has got into difficulties and the child has tried unsuccessfully to save them. They have to live with that for the rest of their lives.

Adults as the driving forceAre concerns about the safety of adult buddies masking a greater issue, that adults charged with ensuring the safety of a child can actually lead it into danger PADI insists that junior divers be accompanied either by their own parents or guardians or by a professional PADI member. PADI Divemasters and Instructors will have received rescue and first-aid training and should be able to search for a missing diver. However, no such requirement is placed on parents. A qualified entry-level diver is expected only to be able to tow a casualty on the surface. Other skills essential to locating, recovering and administering first aid to another diver are not taught. Some professionals believe partnering children with adults who have not been leadership-trained is asking for PADI and SSI set very specific restrictions on child-diving activities. The question is, will anyone abide by them For 12- to 15-year-olds, the maximum depth to which they may dive, even with advanced training, is 21m. Jeremiah Douglass made a planned dive to nearly twice that depth with his father, who was a qualified instructor. In the case of the young spearfisherman, he was diving to 30m. If there is evidence that the safety rules are being broken in the 12-15 age group, will it be any different for 10- and 11-year-olds with their supposed 12m limit Apart from its often cold and in places deep waters, another factor that led Capernwray to insist on a 12-year-old minimum age for diving was - parents. In many cases, in my experience, often through an excess of affection for their child and a desire to involve the kids as quickly as possible in their own chosen sport, they fail to see or fully consider the inherent dangers of sub-aqua diving, particularly in British conditions, says Dave Hack. The nightmare scenario, which has happened here more than once, is the arrival of the newly qualified family. I watched a family like this some years ago on their first dive together since qualifying and I confronted the parent after the first dive to express my concern that his dive profile, a series of descents to 18m followed by a rapid ascent to the surface after just a couple of minutes, then the same again as they progressed around the various buoyed wrecks in the quarry, might be extremely provocative in terms of inviting decompression illness. When I was met by a blank expression, I knew we might have a problem! On this occasion, the family listened to his advice, sought further training and went on to become competent divers. But were those children properly supervised in the water Was the parent in a position to look after his own offspring had something gone wrong And could those children have helped their father had his dive profile led to a serious in-water incidentHack believes parents of younger children are best advised to get them involved in clubs, developing good water skills through snorkelling, or trying scuba-diving but in the pool under close supervision. Think long and hard about what might go wrong, and how you would cope if you took your 10-year-old on a dive on a cold winters day and the unthinkable happened. Young blood is good for the sport and good for business. But diving isnt football, its an adventure sport with inherent risks and takes place in an environment that will bite you if you arent properly trained and dont follow the rules. Adults understand those rules but Im not sure if a 10-year-old can really be expected to.

What protects the kidsThe diving industry is poorly policed. Spot-checks of facilities are made by the HSE and some training agencies, but these rely largely on chance to discover a problem, especially given that diving takes place under water and out of sight. So what policing there is tends to be reactive, rather than proactive. Following an incident, investigations might be carried out by training agencies if their members were involved, by the Health and Safety Executive, which oversees professional diving operations, and by the police and local authorities. Standards of enforcement may well be even lower abroad. Certainly it is difficult for a non-diving parent to assess the quality of care on offer to his or her child. The Lyme Bay tragedy of 1993, in which four teenagers died during a canoeing trip, raises further issues. The case set a legal precedent when Peter Kite, Managing Director of Active Learning and Leisure, became the first person to be convicted of corporate manslaughter. Kite had ignored written warnings from members of staff complaining of safety shortcomings. Kite served a prison sentence and the company was fined £60,000. Owners of dive centres could face similar action if it was found that they could have reasonably foreseen incidents that led to injury or death. For example, the police might have grounds for prosecution if a child drowned because an instructor loaded the pockets of a BC with weights and zipped them shut, rather than using a conventional weightbelt or integrated BC, designed for emergency jettisoning. It became clear during the Kite trial that the instructors responsible for the childrens safety on the water put to sea without adequate safeguards. Could a similar situation arise on a diving course or excursion Butch Hendricks is again outspoken on this issue: Our industry continually brings up the issue of responsible divers, and yet ignores the concept of responsible instructors. After 39 years of teaching diving for a living, and spending most of those years working in diving education, instructor training, safety and rescue, it is my opinion that the average instructor does not have the experience or expertise to teach 10-year-olds or take them diving. Divers Alert Network has data to process which might confirm or refute such concerns. When I asked about accidents involving under-16s, DANs Vice President of Medical Services Joel Dovenbarger told me: We are looking at the same thing for injuries and fatalities over the past five years, but it is scheduled for later in the year. At present we are working on the year 2000 data and collecting 2001. It is not clear when DAN will release its report. So what is the industry consensus Should 10-year-olds scuba-dive Inevitably, there are no clear-cut answers. Diving Diseases Research Centres Medical Director Dr Phil Bryson tries to unbend divers and sometimes return them to life. Speaking personally rather than on behalf of the DDRC, he told me: I would not let my daughter dive until she was at least 14 to 16, and probably not till later than that. However, he added, this may be because I treat divers who suffer decompression sickness and could be classed as somewhat biased! Alfred Bove told me: I dont have an objection to teaching diving to 10-year-olds. They must be selected for their maturity and ability to learn, and understand the risks. A child will always need an adult as a diving companion. I have a 10-year-old grandson, says Butch Hendricks. He loves to snorkel. But the concept of putting a scuba tank on him, based on his maturity, is questionable. And as an industry of mediocrity and dilution, I am concerned about where we go from here. Eight-year-olds Seven-year-olds How far are we going to push the envelope

Additional research by Andrew Pugsley

THE WORD FROM THE KIDSWill Burns is a Master Scuba Diver, PADIs highest non-professional grade. Where does he go from there Anywhere, really - hes still only 14. Master Burns is one the youngest PADI Junior Divers in the world to have attained this exalted level. A keen holiday snorkeller, he had embarked on an Open Water course when he was 12. I thought diving looked interesting and that it would be fun to see the underwater life, says Will. But I soon found that it wasnt just a matter of attaching a cylinder to your BC and rolling off a boat! When I got to the advanced level, with deco stops and nitrogen narcosis and so on, I realised I was getting in a bit deeper. I didnt find it too difficult, but there are different kinds of people. Some arent as clever as others, and it all depends on how good your instructor is. Theres a big difference between a 10- and a 14-year-old, but Will is still close enough to 10 to judge how he might have coped with a course four years ago. It all depends on how you explain it, but I dont think I would have been able to understand the theory at that age, he says. I feel that anyone aged below 12 should not start courses - I found it quite advanced and I was 12 coming on to 13. I honestly reckon 10 is pushing the boundaries a bit, not just for the divers sake but for the sake of other divers. I feel I have matured and like physics much more due to the amount of information that had to be learnt through the My concentration and listening skills have become better since I started diving, due to the number of instructors Ive been taught by. Ive never found the courses Ive completed too much to handle, but there were a few individual parts that needed to be explained more than once! Since Im big for my age, I dont really struggle with the physical side of diving, although there are times when I do struggle to walk on rocks with a 12 or 15 litre tank attached to my back! He also agrees that younger children are likely to panic in an emergency. Theyll be asking: What should I do and there might be no one to tell them. Wills father Peter believes that, exceptional though Will is, he was just on the limits when he started learning. If the adult in charge had had a problem... Will certainly got onto the Advanced Diver course at the earliest point possible. There do have to be restrictions on depth and the sort of places a 10-year-old can dive.